RUH hospital has apologised for its part in the death of a disabled woman that has been investigated as part of an Safeguarding Adults Review. The woman, 67, known only as Patient E went from a jovial and determined person to bed bound and later contracted hospital acquired pneumonia and died in an acute hospital bed.

In the months before she died, she began to struggle to continue living in supported living with her ill health and went to hospital four times after fracturing her ankle, and another for becoming dehydrated.

She went back to hospital after fracturing her leg and carers became concerned she wasn’t eating or drinking. She spent a week in the Bath hospital with a fractured leg, before being moved to Savernake community hospital in Marlborough. One day later she returned to hospital, and the follow day she died.

A safeguarding review panel heard she was moved back and forth between community hospital and acute hospital and her symptoms were mistaken for characteristics of her learning disability.

As a result, her deteriorating health was not picked up quickly enough.

Despite observations indicating she was not ready to be discharged, she was moved to the community hospital. A Healthcare Passport, containing information about Patient E and her characteristics and health needs was lost during the move, which could have made it harder for staff to see that Adult E was not behaving as she normally would have if she was well enough to be discharged, the panel found.

The healthcare passport has been described as a patient’s “voice on a page”.

The report found that poor communication between the hospital and her care agency was a particular issue and family told the panel that they had found it hard to find what hospital she was when they wanted to visit.

When they finally did visit her, they did not realise they had been called in to make a decision about the withdrawal of medical care for their loved one.

Her usual carers reported feeling pressurised to help discharge her and one said “I felt like I was bed blocking, preventing someone from coming home.”

Patient E had learning disabilities and had received care from carers throughout her life.

However when she was admitted to hospital with a fracture, her carers resorted to visiting her in their own time after being told they had not been funded to continue to give her care.

A spokesman speaking on behalf of the RUH hospital to the Wiltshire Council Health and Wellbeing Board said: “We are sorry, as an institution and as caring people what happened to Adult E and for any part we were involved. We take this very seriously to get a better understanding of what goes on. It is helpful these issues have been brought into focus. We have made learning disabilities a key theme for the last two years work at the hospital and we are doing very dynamic work.” My concern is that sometimes means we have a lot of specialist resource like disability nurses which mean people in the mainstream don’t have to know about it. We need to make sure all professional are aware and not just leave it to specialists.”